The debate around the efficacy and ethics of teletherapy is starting to fade as more state boards, professional organizations, law makers, therapists and clients realize that virtual sessions can be as supportive and helpful for some clients as in person sessions.
Additionally, for those clients who are home bound due to illness, injury, infirmary, age, physical limitations, limits in driving, or for those who have recently given birth, are undergoing medical treatment or chemotherapy, or live in a remote location, teletherapy, telehealth, virtual telemental health services can be the difference between not receiving any care at all, to receiving excellent virtual support from a licensed mental health provider.
As this modality gains popularity, there seems to be some confusion among therapists on the particulars of providing focused clinical support via telehealth sessions.
Note: The terms Teletherapy, telehealth, and virtual therapy, virtual counseling, and tele mental health will be used interchangeably in this article.
Before we get started...
The aim of this article is not to cover every aspect of HIPAA compliance, or to discuss insurance and managed care reimbursement (I do not work with insurance panels, my therapy clients are fee for service, thus I am not an expert on managed care). Nor will I attempt to explore the fine points of a particular clinical modality and how effective virtual counseling is within that modality.
Rather, I want to touch on important questions that most often come up in my coaching sessions with respect to telehealth provision. I share the following information as a therapist who has provided effective tele therapy over the last 10 years, who has a certification in telemental health, who has discussed at length telehealth with CAMFT attorneys, (The California Association of Marriage and Family Therapy), and as a business coach to therapists, and one who has done extensive research on this modality.
My sincere hope is that the following information will be of support for those of you who are currently providing teletherapy, or are considering stepping in to telehealth sessions. Please understand that this article does not act as legal advise, nor does it replace legal consultation.
Additionally, I am not advising you on how to provide teletherapy services. And because laws change, it is important to stay abreast, and not to rely on a blog, or a friend, or a colleague to answer legal questions related to this topic.
Also, in spite of how we may feel about current laws that prohibit providing therapy out of one's state of licensure, and even though many of us, myself included, would like to see these laws changed, and are advocating for changes, as it stands currently we may not provide therapy out of the state we are licensed in.
Good to remember that calling psychotherapy "coaching" is not a loop hole. If you are a licensed therapist and you choose to frame your therapy services as coaching, you will have to assume the risk in doing so. In that case, it may be wise to obtain a Life Coach certification through a respected organization so that you at least have that in place to support the work you are doing if you are providing "coaching" services to clients seeking that kind of support. Always check with your state board on the legal requirements. We work so hard for our licenses - better safe than sorry.
Finally, before we jump in to the good stuff below, it is important to note that I am not affiliated with, or an affiliate partner to any of the organizations or platforms I discuss. As a coach to therapists, I prefer not to enter in to paid affiliate relationships as I want the recommendations in my blogs, articles and on my website to be provided without any incentive or monetary reimbursement for doing so.
As of this blog, FaceTime is not yet a HIPAA compliant way of meeting with clients. Though we all love our smartphones, please do not provide therapy this way.
Skype is a video conference platform that most of us are familiar with. We love it because it is free and easy to use. However, as of January 2016 Skype is still not HIPAA compliant as it does not provide the therapist with what is called a BAA or Business Associate Agreement, and it does not alert clinicians if a breach of confidentiality occurs. Hopefully this will change in the future. Vsee.com and Doxy.me are both popular HIPAA compliant platforms that do offer BAA agreements (usually for a fee).
There are other platforms, Adaptive Telehealth for example, that offer an integrated approach with services that go beyond HIPAA compliant video conferencing, These integrated platforms provide a truly virtual experience for the clinician and client such as payment, encrypted messaging, file storage, client notes, client calendars, audio, video, group conferencing and so forth. This comes with a higher fee, but also a higher level of convenience and security for many therapists and clients.
That said, if you have a HIPAA compliant way keeping and storing client forms, notes and paperwork, and you have a way of charging clients and scheduling sessions that adheres to HIPAA, you may not need an integrated platform. In that case you can simply add a HIPAA compliant video platform (like Vsee or Doxyme) to your existing HIPAA compliant practice and process.
Do your homework, compare, make sure you/the platform have a BAA in place, and decide what makes the most sense for you and for your clients.
Client intake forms for teletherapy clients should include the same information that non-telehealth client forms contain. Make sure your forms, in person or telehealth, include the following:
Your name and title and license number
Your DBA (if you have a DBA)
Client's full legal name and age
Name client prefers to go by
Limits of confidentiality
Your fee (shared before your first session)
Your cancellation policy
Contact between sessions
Social media boundaries
Illness policy (boundaries for clients not arriving to session ill)
Your time away policy
A Bio/Psycho/Social assessment
Previous therapy history
No secrets policy (for couples)
If you prefer not to reinvent the wheel, you may purchase my Complete Client Intake Forms Packet here. This packet includes all of the above, as well as a super bill, no suicide contract, and other important information.
Additionally, if you will be working with clients via teletherapy, you will minimally want to add the following information to your forms:
Remind client that you will need to verify via an ID or Driver's License they are who they say they are
No driving during a teletherapy session
No drinking alcoholic beverages or smoking marijuana or taking drugs during a teletherapy session
No recording sessions without the therapist’s permission
The client will need to verify their address or location at the start of each teletherapy session (in case of a suicide threat or crisis)
The client will need to verify that they are in a confidential location at the start of each teletherapy session
The client will need to verify that there are no other children or adults in the room with them during their teletherapy session
The client may not be located in a different state than the state you are licensed in during the tele therapy session because a therapist may not provide therapy out of the state the therapist is licensed in.
There are 3 exceptions to this rule: 1. As of 2018 Federal Agencies can provide support over state lines, 2. A therapist can extend temporary follow up to ensure your client is not in crisis, and 3. If your client is in crisis and is visiting a different state, for example the client emails you or calls you and tells you they are planning to take their own life, then you must always fall back on the highest standard of care and help the client. This could be done by calling the police in the city that the client is visiting and asking for a wellness check for example.
Tele therapy Client Assessment
The same level of clinical assessment applies to a tele therapy client as an in office client. For example, we would assess if we are the right clinical fit for the client (and visa versa); we would provide a clinical assessment that includes a bio/psycho/social assessment; if there is a need for a psychiatric evaluation, medical check up, we would make that referral; if the client is in crisis and requires a higher level of care; if adjunct support is necessary (EMDR, Group Therapy, 12 Step, Couples Therapy); if there is suicidal or homicidal ideation happening; and if this client is a good fit for teletherapy/telehealth services in general, and if we are operating within our scope of clinical expertise.
Here are basic assessment questions that are important to ask and document:
Do they reside within your state of licensure?
Are they actively suicidal or homicidal?
Are they in crisis that would require a higher level of care or in person care?
Does the client requesting telehealth have a place to meet you via teletherapy that is confidential?
Do they have uninterrupted access to the Internet?
Can they provide a driver’s license or ID that verifies they are who they say they are and their age? (NOTE: confirming the client's age is important for potential reporting responsibilities)
Do they understand how technology works?
Are they competent and cognizant?
Are they comfortable with technology, or will this interfere with their ability to process?
Are they able to focus during a teletherapy session, or are they distracted?
It is important that you assess if you, the clinician, are competent to provide tele mental health services, and if you can be present and focused during tele therapy just as you would be in the clinical room one-on-one.
Client Crisis Considerations (more on this below)
Additionally, you must have a crisis plan in place when providing teletherapy. This would include mandated reporting duties, suicide and homicide threats, wellness check by the police in case of a suicide threat, in patient, tarasoff responsibilities, and alerting authorities to the client’s location should a crisis happen during session.
Consider this hypothetical crisis situation:
Jane is your telehealth client. She is a 21 year old college student and a resident in your state of licensure who read your book/blog/heard you on a podcast/saw you speak/ connected with your website/read an article you wrote, etc. and contacted you because she would like to work with you via teletherapy. Jane shares that her reasons for attending therapy is to reduce her depression due to feelings of loneliness and sadness in being separated from her friends and family for the first time.
After an initial assessment, and offering to provide Jane in person therapist referrals in her area, and Jane still choosing to work with you (and you documenting these steps), you have Jane fill out all of the intake forms and proceed forward on a HIPAA compliant platform and begin your clinical assessment and treatment planning steps.
During your 4th telehealth session Jane reveals that the primary reason she is feeling depressed is due to a violent rape at a frat party 6 months prior. She then begins to sob, and shares that she no longer wants to live, and indicates that she wants to end the session prematurely and will be taking her own life when she ends the session. She shares that she is serious in her intention and describes hoarding the drug Ambian in order to over dose. Jane then abruptly ends the call.
Questions to consider:
Do you have Jane's current address?
Did you verify her address, dorm, room number and college at the start of your session and write this information down in your notes?
Was Jane in her car on campus in a private area? If so, did you confirm her exact location on campus?
Do you have the number of the college campus security?
Do you have a this outlined in your forms in a way that lets the client know that you will be contacting an emergency person, the police, or their academic security if they are threatening harm to self or others?
Has the client signed your forms?
If you do not have this information on hand, how will you provide Jane’s location to the proper parties?
And if Jane suddenly terminates the session, do you know what your next steps will be?
Here is a second hypothetical crisis scenario to consider:
Barbara is a 60-year-old female who has been working with you in your office for face-to-face sessions for a year. Barbara has recently left her 55 year old husband of 25 years due to domestic violence. She has been living with her daughter for one week. Her daughter lives three hours from your office, but still within your state of licensure. You offer to provide referrals for Barbara for in person therapy, however, Barbara has bonded with you, trusts you, and wants to continue her work with you via teletherapy, and shares that she is comfortable with technology, and has a private room for confidential sessions, and would like to schedule a session with you ASAP due to her increased anxiety at leaving her husband.
You agree to meet with Barbara the following day via teletherapy as a support. You haven’t yet updated her new address in her client file, but plan on doing that during the session.
At the start of the session, just after saying hello and before you have updated her address, Barbara immediately becomes alarmed by the sound of breaking glass. Suddenly Barbara’s estranged husband bursts in to the room and begins to assault Barbara and disconnects the session.
Questions to consider:
Do you have a crisis policy in place?
Did you discuss a DV safety plan with Barbara?
What are your next steps?
If you did not update the address prior to the session, where will you direct an emergency team?
As you can see, crisis intervention and a solid tele health policy is imperative with clients utilizing tele therapy services.
Reminder on Public Wifi
Beyond holding legal and ethical boundaries around not working on clinical notes in public, clinicians must also exercise caution in upholding client confidentiality when using their clinical devices in public.
So when you are traveling, or at a coffee shop, hotel, or restaurant, you must be cautious about using the public WiFi for clinical client information that could breach HIPAA. Public WiFi is not secure, so this means if you are using your smartphone, the same phone you use to text or email with clients, then you must go to settings and access your cellular data plan to prevent using public Wifi.
One solution is to utilize what is called a “HotSpot Device” (you can google or look on Amazon for this). Hotspots are HIPAA compliant and are a great way to stay off of public WiFi therefore securing your client’s confidentiality.
Keep in mind that this can impact speed, and that you will want to double check with your provider on the limits of your data plan so that you do not run over minutes and start wracking up a large bill. Check your plan, speak to your provider, and see what options are best for you.
As of January 2018, therapists in the State of California and many states are not mandated to obtain certification in teletherapy telemental health services (yet!).
However, I believe it is wise to invest time in learning about this emerging industry and seek out a certification so that you can provide the highest standard of care for teletheapy clients.
There are several certification programs that provide telehealth certifications. It is wise to do your research, ask colleagues for their recommendations, and find an accredited CEU provider for telemental health certification.
I received my telehealth certification through Zur University (I have no affiliation or affiliate partnership with this organization). I found that their on line certification program was comprehensive, convenient, self paced and affordable. You can Google their website if you would like to check out this resource.
Common Sense Considerations for the Telethealth Clinician
Most of the following falls under the category of “No shit Sherlock!”, but worth outlining regardless. If you are providing teletherapy please be sure that:
You are not providing therapy over the state line that you are licensed in
You are not providing letters (for example support animal letters) to the client in a different state
You may not market your therapy services in a different state if you are not licensed in that state
Your client is residing within the state you are licensed in
Your client is not out of state during their tele therapy session (you may be held to the licensing laws, penalties and fines in both states if something goes awry during your session).
NOTE: Check with your licensing board to ensure that you can provide therapy if the client is, for example, vacationing in a different state, and if so, ask if you will need a consent from the client or that state board. Your board may advise you to call the board in the state your client is visiting to obtain permission for you to provide therapy sessions to the client while they are in that state.
You are not providing Psychotherapy and calling it coaching; even if you are providing coaching remember that if the coaching client sues you you may have to travel to the client's state to defend yourself
International therapy is considered very precarious and high risk as we do not know the law of the land in another country. You will likely have no idea if you are breaking particular laws, and if you were sued, you may have to travel to that country to defend yourself
That the platform you use is HIPAA complaint and that you have a BAA on file
You are in a confidential location
You are not driving, in public, or distracted
You are dressed neatly and appropriately
Your background (the area that the client can see) is professionally maintained (you will likely not want to have personal photos, posters, art, political or religious information, bills, etc. on display)
Your child is not in the room
You are reducing sounds in your environment as much as possible, including pets, children, ringing phones, music, gardening, and construction
You do not eat during a teletherapy session
You are not browsing the Internet, checking email, or responding to texts during a telehealth session
You do not consume alcohol or smoke during a teletherapy session
You do not go to the bathroom during a tele therapy session (if you need to use the bathroom, excuse yourself from the session just as you would during an in person session)
You do not have pets sitting on you unless the client has indicated they are comfortable with this and the pet is not distracting (I love my rescue pets, but they might be distracting to a particular client)
You are using a headset if need be
You do not ask the client to hold while you take another call or answer your front door
You may want to consider purchasing a do not disturb sign for your home office door, and your front door
That you have a plan in place if the call or video is dropped (is the client calling back, or are you?)
What about Out of State Subpoenas?
Great question! If you receive a subpoena from an out of state attorney regarding your client (client now lives out of state), contact your liability insurance. For example, my liability insurance company is CPH. If this happened with me, I would contact CPH, explain the situation and then they would assign an attorney to walk me through this.
How about if a client requests a file?
Another good question! A former client who now lives out of your state may request a file, responding to the is request is fine because you are not providing therapy services over state lines - you are simply responding to the former client's request.
However, make sure that you first receive a signed authorization from the client, and then clarify what they are authorizing. For example, do they want their entire file? Do they want a file summary? Document baby!
Also, always wise to reach out to your membership organization (my own is CAMFT) to double check you are handling this request legally and ethically. No question is a dumb question when it comes to handling client requests. Better safe than sorry. Always.
Appropriate Teletherapy Environment
Setting the stage for video therapy is very important. It is respectful to the client to make sure that the environment that you and your client will be "meeting in", the space your client will be viewing virtually is clean, warm, and clinically appropriate.
Note: I included the photo to the left because I like the feel of this home office. But you can also create a cozy private space if you do not have an extra room.
As discussed previously, the main consideration is making sure that your space is confidential, that sound is not carrying between walls, and that it is private.
If you do not have an entire room to spare in your home, I understand. I have a small home and when I am conducting tele therapy sessions, I most often use my combo den/office/guest room as my tele therapy office.
Here is a photo of that space. I created a room that is sunny, with neutral light colors. The desk I sit at is opposite the couch. You can see from the angle of this photo what the client would see when meeting with me for a tele therapy session.
If I sit on the couch, I place my laptop in front of me on the small table on a stand. And the background is a muted sunny window with a uplifting piece of word art.
If I sit on the chair in the lower right corner, I slide the small table closer to me and put the laptop on a stand, the back ground from that perspective is a bookshelf.
If you do not have a room that you can use as an office, then you can select a corner of your home to conduct your tele therapy sessions in (as long as that corner is private, will maintain confidentiality, and is not distracting, is not open to others, etc.).
Here is a photo of a corner in my living room that I use from time-to-to time, especially on cooler days or evenings when I can light the fireplace. I bring in the small table from the den/office room (see photo above) and set that in between the chairs. I put my laptop on a stand and angle it toward the chair and fireplace.
My clients share that they love the cozy feeling of our "fireside sessions" and some even request this from time-to-time. Your home office does not need to be big or fancy, it simply needs to be functional and respectful of the client.
If you will be using your clinical office space for your tele therapy sessions (and I do that as well), then again, make sure you test out the angle and lighting and visual comfort for the telehealth client. Don't be afraid to get their input and what feels best for the client visually. Here is a split screen photo of my own clinical office at my counseling center. The photo is taken from two angles to help you get an idea of the space.
The desk in the background in the right photo is where I typically conduct my tele therapy sessions, though sometimes I sit on the chair or the couch and place my laptop on the small table in front of me (left photo).
Note: If you need support in setting up your counseling space, my former career was in Interior Design and I offer support to colleagues. You can learn more about my design consulting here.
And here is a final photo of my previous counseling office. Again, the angle of the laptop, and vantage point of the tele therapy client gave them a small view of a private little garden area, a low lit lamp, my degrees and license, and vase of flowers. Keep the background simple and uncluttered so that the client is not distracted.
If you will be using your laptop to provide therapy, make sure that you get a stand, and that it is at eye level and consider the distance between your face and your client's face on the screen. There is research about the distance between the client and therapist, as well as eye contact via telehealth. You can Google to learn more about this.
It should go without saying that your electronics will be important tools for your telehealth practice. Thus, making sure you have an up-to-date laptop, smart phone and possibly a tablet are essential. Your supplies should include back up chargers as well.
Once you have your environment set, I suggest that you have a friend or loved one sit in the chair, or at the desk and you call in to see what that would look like from your client's perspective. Is there a glare from a window? Is the lighting too dim? Did you notice that your home address is showing through a window? Is a mirror reflecting something you’d rather not have the client see? Is there art that could offend the client? Are family photos showing? Is there a glare on your glasses if you need specs to see the client on the screen.
A neutral environment with a comfortable chair, desk with your laptop at eye level in front of you, bookshelf (with professional books), plants or flowers, a candle, a clock, is appropriate. Personal items to warm up the environment are fine, but do consider what information you will be sharing with the client through those items that they will be viewing virtually during their session.
Set your virtual office “stage” and then double check the appearance of the background. And, keep it consistent for your client so that they see the same environment each time you meet virtually.
Also, be open to feedback from clients, ask them if there is something they would like to change. For example, I had a client share that the striped throw that I had on my chair was “vibrating” on the screen and making her dizzy. So I replaced in with a solid color throw and that solved the problem.
I've had other clients that prefer not to have the camera on. I ask that the client confirm that they are in a confidential setting, check their address, and then proceed with audio only. My clients know that every few sessions I will need to see them either via video therapy or in person to visually assess as needed.
Final Tips for Providing Legal, Ethical and HIPAA compliant Teletherapy
Operate within your state of licensure
Have signed consent forms in place before you begin working with the client
Have a contingency plan if your connection is dropped
If you are conducting the session via phone, who is calling whom back?
Always double check the client location and address, add this to your notes immediately at the start of every session
Always double check the client is in a confidential location
Update your client's address if they move, do this before the session if possible
If you suspect there is a person in the room with the client, ask that the client scan the room by reversing their phone, tablet or laptop so that you can visually “see” the room (Reminder: if on the phone, they would be meeting you on a HIPAA compliant platform, not via FaceTime)
Remind clients that recording is not acceptable (unless you have agreed that the client may do so)
Make sure you are dressed appropriately
If a child or someone else interrupts the client, let the client know that you will be silent until the person leaves
And, equally important, remember to make it safe for your clients to move from teletherapy back in to in-person office sessions at any point. If that is not possible (because they live too far from your office or you no longer work with clients in person), then let the client know at any point should they prefer working with a therapist in person, you are happy to provide referrals in their area.
There is so much more to cover on this important and emerging field of telemental health services. As a therapist who works via tele therapy and in office, I am excited that we have an ethical way of providing virtual support to help hurting people heal.
I’ll wrap up for now with a final word of encouragement: Please continue to do your research, stay abreast of current legal and ethical developments and requirements, make sure you have your forms in place, have a BAA agreement with the HIPAA compliant platform you choose, consult with an attorney or your boards as needed, and obtain a telethealth certification so that you are aware of HIPAA requirements, legal and crisis considerations, and best ethical practices.
I hope that the information I have provided here helps support your practice goals and dreams. If you would like to ask a question or introduce yourself, you are welcome to do so in the comment section below.
If you are interested in learning what other colleagues have to say about my coaching support, you can read more here.
Thank you for stopping by! And feel free to introduce yourself or ask questions in the comment section below.
Kindly and in support,
Mari A. Lee, LMFT, CSAT-S
The Counselors Coach